UK Healthcare earned a 2014 Gage Award honorable mention for quality.
In 2009, the observed to expected mortality ratio at UK Healthcare hit historic highs. At the time, adverse events were addressed at the department level using a decentralized approach that delayed investigations and failed to stop recurrences. The hospital responded with a centralized approach that changed the culture of blame to one of open dialogue and fostered a systemwide commitment to continuous improvement.
SWARMing to the Site
Before developing its own approach to adverse events, the hospital reviewed the problem-solving methods of other organizations. Staff studied techniques from NASA, which relies on root-cause analysis; the Veterans Administration, which uses triage cards; and Toyota’s lean management principles. Taking cues from each of these methods, UK Healthcare developed SWARMing.
A SWARM is initiated as soon as possible after an adverse incident or undesirable event occurs. Like bees, staff swarm to the site to determine the cause of the event and how it can be corrected. After the event is identified, staff complete the following steps:
- Frontline staff complete an incident report.
- The department administrator, risk management manager, and Office of Enterprise Quality and Safety evaluate the incident report and instruct the relevant participants to SWARM as close in time and physical proximity to the event as possible.
- Relevant staff SWARM in a blame-free environment to quickly analyze what happened, why it happened, and decide what needs to be done to prevent it from happening in the future.
An effective SWARM includes the following five steps:
- encouraging candor by reassuring participants that they are in a blame-free environment with legal protections
- introducing all participants to create a common familiarity and respect
- reviewing the facts that prompted the SWARM
- discussing what happened and theorizing about why and how it happened
- proposing focus areas for action and assigning task leaders with specific deliverables and completion dates
Participants choose one representative to lead the process and ensure all other task leaders perform their duties as assigned and on schedule. Staff aim to complete all follow-up for a SWARM within 60 days.
Adapting the Technique for Maximum Value
UK Healthcare developed an effective process for SWARMing through trial and error. For example, SWARM participants were reconditioned against preparing too much for a SWARM when staff found that it tended to shut down effective conversation.
When staff found that the number of SWARMs was creating alarm fatigue for administration, they started hosting unit-level SWARMS – as opposed to enterprise-wide – for incidents that can be resolved without hospital leadership involvement.
UK Healthcare has hosted more than 700 SWARMS, focusing on events ranging from patient falls without injury to unanticipated death. The SWARM process has been accepted by The Joint Commission as a suitable root-cause analysis for sentinel events.
Since instituting SWARMs in 2009, the hospital has experienced an overall reduction in the observed to expected mortality ratio from historically high levels of 1.5 to 0.7.
And finally, implementing SWARMs has led to a new culture of responsibility within the organization. In the past, time lapses after adverse events and accusatory resolutions led to a culture of blame. With SWARMs, problems are addressed in a blameless environment in a timely manner. By eliminating the culture of blame, the hospital created an environment of responsibility for patient safety. Staff now more easily recognize potentially harmful patterns and act to report processes and protocols that are not working.
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Clinical Risk Manager